Multifetal Pregnancy Reduction

Note: The term used by the International Society of Twins Studies (ISTS) is “Multifetal Pregnancy Reduction” and is the one used here. For the Reader’s information, this procedure may also be referred to as “Selective Reduction”.

Couples who are expecting three or more babies may wish, or be advised, to consider reducing the number of viable fetuses to two. The reduction procedure is usually performed between the 10th and 12th weeks of pregnancy by injecting one or more of the fetuses. Fetal reduction increases the chance of a mother having one or two healthy babies instead of a miscarriage or very premature delivery of three or more babies who are much more likely to die or to suffer from long-term disability.

The balance of risk and advantage will be different for each couple but nevertheless for all there will be a sense of responsibility and much anxiety. For couples considering multifetal pregnancy reduction, there are additional issues that compound their anxieties.

Firstly, many couples have struggled with becoming pregnant, sometimes for years. Here they are pregnant, with some type of fertility assistance, but they are carrying triplets, quadruplets, quintuplets, sextuplets or more. To now have to consider reduction (killing?) of some (or even one) of the babies that they have strived so hard to conceive, goes against all of the time, energy, disappointment, heartbreak and money that was invested in getting pregnant in the first place.

Secondly, when it is determined that there are three or more fetuses, the timeframe for the multifetal reduction choice is often very narrow, sometimes as short as only 3 or 4 days. In that small window, the parents have to learn all they can about the procedure, perhaps connect with others who have had the procedure, learn about the risks to mother and the remaining fetuses and come to grips with losing (aborting? killing?) one or more of their unborn children. This is enormous pressure to endure, to come to terms with and to decide upon in a few, short days.

Thirdly, and as yet perhaps one of the most unstudied and unrecognized issue, are the possible long term psychological effects on the parents and by extension, the children as well of choosing a multifetal pregnancy reduction procedure. Some of the questions that have been bandied about my parents having had the procedure are: “Did we kill our son?” (this from parents who had two beautiful daughters from a triplet pregnancy); “Am I a murderer?” “How and when do we tell the others (surviving children)?” Some parents have reported fantasizing about the baby(ies) that was reduced and wondering about the sex of that child(ren), if they would have looked like their co-multiples and even if they should tell the siblings about the reduction. Some parents have named the reduced child(ren) in an attempt to come to terms with their decision and to find some peace regarding this socially unrecognized loss.

Regarding telling the other children about the procedure and what it could entail, once again the answer will be individual and personal. If you have shared with other family members that you are carrying many fetuses and are considering multifetal reduction, then have the procedure and wish to keep hush regarding your decision, it may already be too late. If parents choose not to tell their surviving children but have conferred with other family members regarding the procedure, then there is always a risk that someone will tell, even inadvertently, your surviving children. Secrets in a family are extremely hard to keep and usually fester and erupt at a most inopportune time and sometimes awkward moment. It stands to reason that parents considering the multifetal reduction procedure would want to confer with other family members who love and care for them, as they struggle with emotions, guilt, worry and anxiety over their babies. To share personal information and then to expect silence may be too much. A child who discovers, from someone other than his parents, an important piece of his history can become confused and angry regarding this important piece of his life which has been kept from him.

With families being more open these days and encouraged to speak of their dead baby, this could be helpful all around. It is usually better for children to know from the start that they were once a part of a set. The reaction of each child will be unique and personal and parents will need to provide age appropriate feedback and information to their children’s questions. The beauty of this approach is that, a child asks at his or her own rate and in a manner that meets his or her needs at that time. Expect questions at all stages of their lives.

When considering multifetal pregnancy reduction, there are many questions and the answers will need to be considered individually and as will affect each family’s personal situation. Here are a few common questions:

I am expecting quadruplets and am being asked to consider reducing to twins. I know it is possible to carry healthy triplets, what do we do?

You are correct, many families have carried triplets to a healthy outcome. There are many considerations and only you, your partner, informed healthcare professionals, perhaps other multiple births parents, genetic counselling can help you reach a decision.

Some things you might consider:

Ascertain the health risk vis-à-vis the mother and all of the babies. If one (or more) fetuses have anomalies, you may feel that reduction is the decision to make, thereby giving the healthy fetuses a better chance at a healthy gestation and life.

Learn the survival statistics

  • 70% of quadruplets survive. Of that figure, 50% of them have disabilities ranging through a series of impairments such as blindness, to cerebral palsy. The average gestation for quadruplets is 28 weeks.
  • 85% of triplets survive and 10% impairment rate can be expected, with an average gestation of 30-33 weeks.
  • 98% of twins survive with a 5% impairment rate and the average gestation is 35-38 weeks (NOTE: a singleton gestation rate is based on 40 weeks).*

*Statistics quoted from research paper by V.M, quadruplet Mom who reduced to triplets and gave birth at 34+ weeks to three beautiful, healthy babies. Their weights ranged from 3.12 lbs. to 4.9 lbs. and the family brought them home from the hospital within 15 days.

Did we do the right thing?

This is such a difficult question and there are no easy answers. Even though the timeframe for decision whether to have the procedure or not is so short, be sure and do your homework. Below are some Internet Sites to visit, talk to other families who have considered the procedure, learn as much as you can about the procedure and the possible ramifications. Knowledge is Power and permits you to make the best possible decision for your personal situation.

I must go back to V.M. thoughts and wisdom. As V puts it:

Someone once said to me “make the decision from your head, not your heart”. I agree with the intent of that comment. An informed decision is the best decision. However, you can never really feel good about such a decision, and you will never be 100% certain of your choice. You can survive this and one day you will be at peace with it. Recently I was able to answer a question that had tormented me from the beginning. “How do I ask forgiveness or understanding from that lost child – the one I never gave a change at life?” The answer – there is no need to ask for forgiveness for a child loves unconditionally. The love we have for that child was and is equally returned. It was through love that my husband and I conceived and it was with love that we reduced. It is the love not the loss that I chose to hold onto. Somewhere between your head and your heart, what you know and what you feel, you will find the answer. Allow yourself to listen to both.

We have lost a child(ren). We hurt so much and we cannot share nor openly talk about our pain.

Multifetal pregnancy reduction is one type of loss that is nearly impossible to ‘share’ with others let alone have them fully understand the anxiety and dilemma that has been faced. We conceived many babies and chose to reduce one (or two, or three). While our dream has been drastically altered, we may choose to keep our personal feelings to ourselves and if not, our loss(es) may not be acknowledged, recognized or even fully understood by others in a manner that we might feel fitting or helpful. A sense of isolation coupled with the grief of the new reality can combine to make the pain greater.

It may not be unusual, like a miscarriage, for others to have difficulty in relating to your loss. “Well it wasn’t a baby yet” or “you have others” may be expressed to you. Try and find a caring and understanding person to share your pain and grief with. It might be a special friend, grief counsellor, religious leader, family doctor or bereavement support gorup. Grief is personal and knows no timetable. Grief is a journey not a destination and may require some support at different stages of your life. It is important to recognize the pain, possible feelings of guilt and grief and to work with them, address and acknowledge them. Only then can we move on, forever changed and with a new reality. Don’t be afraid to cry or seek appropriate professional support, if need be.

Sources

Bereavement: Guidelines for Professionals, These guidelines focus on the particular issues raised by the loss of a twin, triplet or more by Elizabeth Bryan, MD, FRCP, FRCPCH and Faith Hallett, The Multiple Births Foundation
Selective Reduction: Research Tools for an Informed Decision, by V.M.
Twins! Pregnancy, Birth and The First Year of Life by Connie L. Agnew, M.D., Alan H. Kein, M.D., and Jill Alison Ganon, 1997, Harper Perennial

Vanishing Twin and Multifetal Pregnancy Reduction: New Reproductive Technologies, New Losses

There are two types of losses which, in my opinion, are often overlooked, not only by family and friends, but also by many professionals, including medical practitioners, therapists and grief counsellors. Those two losses are Vanishing Twin and Multifetal Pregnancy Reduction.

For reasons which can be understood, although debated, one can see why they might be marginalized (it’s an early loss…, “you hadn’t yet had time to bond with your child(ren)” or “at least you still have one [two]”). However judging by the number of e-mails I receive from families with questions, disbelief, concerns and aching hearts, I think, as a society, we need to take a hard and long look at how we are supporting (or seemingly not supporting) families experiencing such losses.

Vanishing Twin (VT) is a surprisingly common situation, certainly judging by how many questions I receive (it’s the most hit-on article on my site). Even as a young girl, I can remember a couple of my Mom’s women friends saying something like, “It’s the strangest thing;  I’ve been bleeding but the doctor tells me I’m still pregnant.”  In hindsight and prior to the advent of ultrasound, I bet some of these women experienced VT.  Not knowing that they did might indeed be their story, and they continued on with their lives, thankful for their healthy baby.

In the messages I receive, parents narrate their stories, desperately looking for hope regarding the empty sac and asking “over time will there be a baby in it?”  Then there is the worry about the effect of VT on the health of the remaining embryo(s). Because ultrasounds are regularly performed at 5-8 weeks, we learn very early that we are pregnant and with how many.  Hence, to learn by 10-12 weeks the situation has changed dramatically is devastating to many families.  Doctors, ultrasound technicians, grief counsellors, friends, family all need to realize that the loss of these much-wanted children is two-fold:  first there is the loss of a baby, and then there is the loss of unique parenting experience. Passing off an early loss as “at least you still have one” is not the way to comfort anyone and only adds to the confusion and disappointment these parents feel while also depriving them of a right to safely talk about their feelings.

Multifetal Pregnancy Reduction (MFPR) is very complicated and in a recent 10-day period, I was contacted by six families facing reduction or who had just gone through it and were comfortable with their decision, and one who deeply regretted the decision and felt pressured to reduce or chance losing the whole pregnancy.  Here too, anyone coming in contact with families facing reduction needs to be in tune with the emotional strain, possibly lasting a life time, of having to decide to reduce.  Yes, a reduction offers a better chance to having healthy survivors; yes, a reduction improves the physical stress on the mother, and yes the brain tells us a reduction makes rational sense in so many instances.  None of this can be repudiated, but it isn’t just the brain making this decision; the heart is very much involved too and will not be ignored.  The heart is already in love with the babies within and wants desperately to believe that the pregnancy will continue to deliver healthy 3, 4 or 5 infants.

In some cases, it will and things work out, and sometimes things don’t work out so well for one or more of the babies.  There is the emotional strain of the decision:  Am I a killer of my baby(ies)? How will I ever tell the others?  When do I tell them?  Do I tell them?  My babies are already bonded in utero, how will a reduction affect the survivors?  All difficult questions and parents need informed guidance and support in finding solutions which will work for them.

MFPR is not a topic that can be easily discussed with family or friends.  The decision is usually made by the parents in conjunction with professionals and peer strangers who are located on the internet (e.g. other families experiencing or looking at reduction, caring support people and organizations who guide them along the rocky path).  Parents can feel very isolated, frightened and alone in making a decision which bears such significant and life altering impact.  If the discussion to reduce does include family members or friends, then it is no longer a “secret” and telling the kiddies of their origins takes on a new urgency so that parents have control over how and when the children are told.

There are no easy answers but one thing is for sure and that is these grieving families need society’s support, comfort, and understanding in a non-judgmental way.  They are mourning their losses and like any grieving individual, deserve a safe place to do so, with caring people all around them who do not minimize or de-legitimize their loss.  It is the least we can do.

By Lynda P. Haddon, Article copyrighted.

Multiple Births Canada
www.multiplebirthscanada.org